3 DESTRUCTIVE HABITS

Lying ______ Blasphemy ______ Smoking _______ Drinking ______ Have you ever had an abortion _________

Temper _____ Lust ______ Anorexia/Bulimia _______ Stealing ______ Constant criticism ______ Gossip ______ Gluttony ____ Fear ______ (List specific ones) ______ Others (List) _______________________ _________________________________________________________

 4 IMMORAL CONDITIONS

(may be secondary conditions)

Homosexuality ______ Lesbianism ______ Bi-sexuality ______ Sodomy ______ Indecent exposure _____ Masturbation _____ Adultery _____ Fornication _____ Incest ______ Rape ______ Bestiality _____ others ______ if so describe here. ________

Have desires of above nature. ________________________________

Have pictures/videos/books of above nature _____________________

5 OCCULT ACTIVITY ( Past or present)

Have you ever played with games of occult nature such as:?

Dungeons and dragons ______ ESP _____ Telepathy ______ Kabala ____ rock music _____ ET _____ Mah-jong ______ Others _________ Have you ever sought or been subjected to as a child, healing through magic conjuration and charming, such as: Removal of warts and burns, or disease etc ______ treated by or through a spiritualist _______ Christian scientist ____ or spirit healer ____ Psychic healing _____ Hypnosis _____ Metaphysical healing ______ Psychiatry ______ Any evil doctrine ______ use of the pendulum ______ Divining _______ all forms e.g. wedding ring, needle and thread, etc. _______ Chromotherapy _____ Colour therapy _____ Trance for diagnosis ______ or any other occult means ___________?

Have you ever sought to locate missing persons or objects by consulting someone with psychic, ______ clairvoyant _______ or psychometric powers ______________________________________

Have you ever practiced table tipping (lifting)? _____ levitation? _____ or automatic (spirit ) writing? ______ things moving on the table? ________ etc. ___________

Have you ever been given or worn an amulet, talisman? _______ Do you possess one for luck or protection? _____ or I Ching? _____ or heathen curios in your possession? _______

Have you or has anyone for you practiced water witching, sometimes called dowsing or divining for water, using a twig or pendulum? ________

Have you ever had acupuncture ( based on 'lines' similar to the zodiac)? ______ or of any sort ______. Have you ever experimented with or practiced ESP? ____ or telepathy? _____

Have you ever been involved in martial art in any form? __________ If so what form __________________________________________

Have you ever practiced meditation? ______ Do you have now or have you ever had a spirit guide ______ Have you ever seen or been involved in satan worship? ______ or worshipped any "angels". Have you ever attended the development circle. _____

Have you ever felt any antagonism against the Jews for crucifying our Lord. ______ Or any anti Semitism. or any other critical feeling involving the Jews. ____________________________________

Are you a practicing medium ______. Are you now or have you ever been a practicing witch or Warlock? ______ Have you visited a psychic, palm reader, ________ or crystal ball gazer? _____ Have you visited any other type of fortune teller? __________

Have you had an imaginary playmate? ______ or any spirit visitors? _____ or ancestors visiting? ________

Have you ever visited a fortune teller who told your fortune by cards ____ tea leaves _______ palm reading ____ crystals ____ energy balls ____ other _________________________________________

Do you read or follow the horoscope? _____ Have you been hypnotized? ____ Have you ever practiced yoga or self hypnosis ? ____

Have you ever attended a seance or spiritist meeting? _____

Have you ever had a "life or reincarnation" reading? _______

Have you ever consulted ( in fun/curiosity or in earnest )

A Ouija board ____ A Planchette ______ Cards _____ tea leaves ____

A crystal ball ______ or any other ____________

Have you had any other dealings or contact with any other type of psychic analysis. __________________________________________

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6 ARTICLES OR ARTEFACTS WHICH MAY BE PRESENT IN YOUR HOME.

Tarot cards ______ Crystals ______ Energy balls ______ Games of occult nature ______ Good luck charms ______ Bracelets ______ Anklets ______ Amulets ____ Colour bands ______ old dolls _____ Maori carvings ______ or any other carvings  ______ Asherah poles of any sort from any Country ____ Bows and arrows, spears _____ or any other weaponry _____ Jewellery _____ Rock music _____ acupuncture needles ______ Occult or pagan religious objects ______ Images or craft ______ objects of the sun god ___ or any other pagan god. _____ Relics or artefacts ______ which may have been used in pagan temples and religious rites ______ or in the practice of sorcery, magic divination, or spiritualism.

Do you have books, comics, or videos on occult _____ Vampires ____ The weird _____ horror ____ or watched it on TV ______ or film _____ or been taught it at school _____ or the false rainbow _____ or any other "new age " book. ___________________________________

Do you have pictures or toys of any demonic images such as those portrayed in Star Wars _______ or watch similar programmes on TV. _________ e.g. The X Files _______ or similar ______ or allow your children to watch programmes such as Aladdin. __________________ _________________________________________________________

Do you read or have in your home any occult, spiritualist or new age books such as: Books on astrology ______ interpretation of dreams _____ Metaphysics _____ religious cults _____ self realisation _____ fortune telling ____ magic _____ E.S.P. ______ clairvoyance _______ physic phenomena _____ or the magical books, such as "Secrets of the Psalms" ______ or the so called sixth and seventh books of Moses ____ or "the books of Miracles" _____ or any books on mind control ______ Meditation ______ altered states of consciousness ______ new age healing. etc, etc, etc. ____________________________________

7 CULTS WITH WHICH YOU HAVE BEEN CONNECTED.  (Directly or indirectly)

Herbert W Armstrong. ____ Hare Krishna _____ Scientology ______ Buddhism ____ Zen Buddhism _____ Meher Baba ______ Hippie-ism ______ Rosicrucians _____ Mormons ______ Christian scientists _____ Baha'i _____ The third way (Gurdjieff) _____ Unity _____

Unitarian ______ Jehovah's Witnesses _______ Transcendental Meditation _____ Unification Church ( Moon) _____ Children of God _____ Theosophical society _____ Theosophy ______ Inner peace movement ______ Spiritual Frontiers Fellowship _______ Religious research of America ______ EST ______ ET _______ The Way _____ The Forum _____ Metropolitan Community Church ( MCC homosexual church organisation ) _______________________________________

Have you ever attended the Swedenborg church ________.

Have you now or in the past been involved in the Masonic lodge _____ or any other secret society _____

Have you lived in any commune or extended family situation where 'new age' teaching is present or people present ______

8 DRUGS

Are you or have been a drug user or pusher ______ If so what kind?

LSD ____ Acid ____ STP ____ Heroin ____ Crack ____ Speed ____ Methedrine. ____ Amphetamines ( uppers ) _____ E’s - Doves _____ Sweets ____ Whizz ____ Sulph ____ Coke _____ Snow _____ Base _____ Crack ___ Wash _____ Rocks _____ Ecstasy _____ Nembutal _____ Marijuana _____ Hashish _____ Pot _____ Dope ____ Grass ____ Puff _____ Ganja _____ Weed ____ Herb _____ Spliff ____ Hemp ____ Draw _____ Smoke _____ Joint _____ Magic Mushrooms _____ Microdots _____ Cannibis _____ THC _____ Cocaine _____ Peyote _____ Pain killers ( addiction ) _____ Glue sniffing _____ or any other ______ if so show here. ___________

9 CONDEMNATION ---- GUILT.

In regard to Past sins _____ Fear of committing sins ____ Unpardonable sin _____ Divorce / remarriage ____ Fear of being unforgiven ____ Unforgiven: e.g. expressed in anger etc _____ any other ______ if so show here ______________________________________

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Please note:    We do uphold the genuine gifts from God however these gifts sometimes need to be tested as stated in 1 John ch4 v1-6   Counterfeits do sometimes occur.

Have you been involved in 'tongues' ____ Baptism of the spirit _____   ( Heard a voice of God (audible or in the mind) _____ Healings _____ Presence of God in thrills, experiences etc, _____ Let go and let God in passive state of mind _____ Tarry meetings _____ Miraculous guidance _____

11 BODY MARKINGS

Have you pictures of tattooed people _____ Have you tattoos on yourself ______ Check for creatures :e.g. snakes, dragons, evil spirits, skulls, sexual and bawdy pictures _____ Have you ever dressed or represented another person at a party or in a play _____ or a demon ______ or any occult being _______ Have you attended Halloween dressed as any other being. _________

If so show details ________________________________________________

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